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Location
Quality
Severity
Onset
Duration
Modifying factors
Change over time
What kind of pain is it?
Visceral
Involves hollow or solid organs; midline pain due to bilateral innvervation
Steady ache or vague discomfort to excruciating or colicky pain
Poorly localized
Epigastric region: stomach, duodenum, biliary tract
Periumbilical: small bowel, appendix, cecum
Suprapubic: colon, sigmoid, GU tract
Parietal
Involves parietal peritoneum
Localized pain
Causes tenderness and guarding which progress to rigidity and rebound as
peritonitis develops
Referred
Produces symptoms not signs
Based on developmental embryology
Ureteral obstruction testicular pain
Subdiaphragmatic irritation ipsilateral shoulder or supraclavicular pain
Gynecologic pathology back or proximal lower extremity
Biliary disease right infrascapular pain
MI epigastric, neck, jaw or upper extremity pain
Ask about relevant ROS
GI symptoms
Nausea, vomiting, hematemesis, anorexia, diarrhea,
constipation, bloody stools, melena stools
GU symptoms
Dysuria, frequency, urgency, hematuria, incontinence
Gyn symptoms
Vaginal discharge, vaginal bleeding
General
Fever, lightheadedness
And dont forget the history
GI
Past abdominal surgeries, h/o GB disease, ulcers; FamHx IBD
GU
Past surgeries, h/o kidney stones, pyelonephritis, UTI
Gyn
Last menses, sexual activity, contraception, h/o PID or STDs, h/o
ovarian cysts, past gynecological surgeries, pregnancies
Vascular
h/o MI, heart disease, a-fib, anticoagulation, CHF, PVD, Fam Hx of AAA
Other medical history
DM, organ transplant, HIV/AIDS, cancer
Social
Tobacco, drugs Especially cocaine, alcohol
Medications
NSAIDs, H2 blockers, PPIs, immunosuppression, coumadin
Moving on to the Physical Exam
General
Pallor, diaphoresis, general appearance, level of distress or discomfort, is the patient lying
still or moving around in the bed
Vital Signs
Orthostatic VS when volume depletion is suspected
Cardiac
Arrhythmias
Lungs
Pneumonia
Abdomen
Look for distention, scars, masses
Auscultate hyperactive or obstructive BS increase likelihood of SBO fivefold otherwise
not very helpful
Palpate for tenderness, masses, aortic aneurysm, organomegaly, rebound, guarding, rigidity
Percuss for tympany
Look for hernias!
rectal exam
Back
CVA tenderness
Pelvic exam
CMT
Vaginal discharge Culture
Adenexal mass or fullness
Abdominal Findings
Guarding
Voluntary
Contraction of abdominal musculature in anticipation of palpation
Diminish by having patient flex knees
Involuntary
Reflex spasm of abdominal muscles
aka: rigidity
Suggests peritoneal irritation
Rebound
Present in 1 of 4 patients without peritonitis
Pain referred to the point of maximum tenderness when palpating an
adjacent quadrant is suggestive of peritonitis
Rovsings sign in appendicitis
Rectal exam
Little evidence that tenderness adds any useful information beyond
abdominal examination
Gross blood or melena indicates a GIB
Differential Diagnosis
Its Huge!
Physical exam:
T: 37.8, HR: 95, BP 118/76, R: 18, O2 sat: 100%
room air
Uncomfortable appearing, slightly pale
Abdomen: soft, non-distended, tender to palpation in
RLQ with mild guarding; hypoactive bowel sounds
Genital exam: normal
Passively flex
right hip and knee
then internally
rotate the hip
Appendicitis: CT findings
Cecum
Abscess, fat
stranding
Appendicitis
Diagnosis Treatment
WBC NPO
Clinical appendicitis call IVFs
your surgeon Preoperative antibiotics
Maybe appendicitis - CT decrease the incidence of
scan postoperative wound
Not likely appendicitis infections
observe for 6-12 hours or Cover anaerobes, gram-
re-examination in 12 negative and enterococci
hours Zosyn 3.375 grams IV or
Unasyn 3 grams IV
Analgesia
Case #2
ABCs of Resuscitation
AIRWAY:
Consider definitive airway to prevent aspiration
of blood
BREATHING
Supplemental Oxygen
Continuous pulse oximetry
Management in ED
Circulation
Cardiac monitoring
Volume replacement
Crystalloids
2 large-bore intravenous lines (18g or larger)
Blood Products
General guidelines for transfusion
Active bleeding
Failure to improve perfusion and vital signs after the infusion of 2
L of crystalloid
Lower threshold in the elderly
NOT BASED ON INITIAL HEMATOCRIT ALONE
Coagulation factors replaced as needed
Urinary catheter with hypotension to monitor output
Management
Early GI consult for severe bleeds
Therapeutic Endoscopy: band ligation or
injection sclerotherapy
Also.electrocoagulation, heater probes, and lasers
Drug Therapy: somatostatin, octreotide,
vasopressin, PPIs
Balloon tamponade: adjunct or
temporizing measure
Surgery: if all else fails
Disposition
ADMIT
Certain patients with lower GI bleeding may be discharged for
Outpatient work-up
Patients are risk stratified by clinical and endoscopic
criteria
Independent predictors of adverse outcomes in upper GI
bleeding (Corley and colleagues):
Initial hematocrit < 30 %
Initial SBP < 100 mm Hg
Red blood in the NG lavage
History of cirrhosis or ascites on examination
History of vomiting red blood
Abdominal Pain Clinical Pearls
Significant abdominal tenderness should never be attributed to
gastroenteritis
Incidence of gastroenteritis in the elderly is very low
Always perform genital examinations when lower abdominal pain is present
in males and females, in young and old
In older patients with renal colic symptoms, exclude AAA
Severe pain should be taken as an indicator of serious disease
Pain awakening the patient from sleep should always be considered
signficant
Sudden, severe pain suggests serious disease
Pain almost always precedes vomiting in surgical causes; converse is true
for most gastroenteritis and NSAP
Acute cholecystitis is the most common surgical emergency in the elderly
A lack of free air on a chest xray does NOT rule out perforation
Signs and symptoms of PUD, gastritis, reflux and nonspecific dyspepsia
have significant overlap
If the pain of biliary colic lasts more than 6 hours, suspect early cholecystitis